Clinical Management of COPD and Chronic Leg Ulcers in Geriatric Patients

Posted on Nov 7, 2025 in Nursing

Brenda Brown: 76-Year-Old Patient Profile (COPD & Ulcers)

Patient Profile and Clinical Concerns

  • Name: Brenda Brown, 76 years old
  • Past Medical History (PMH): Chronic Obstructive Pulmonary Disease (COPD, specifically emphysema), chronic leg ulcers, active smoker.
  • Social Context: Lives alone, widow, reduced family contact, poor nutrition, low appetite, social isolation, high risk of self-neglect.
  • Concerns: Breathlessness, recurrent respiratory infections, immobility, sacral pressure damage risk (sore bottom), falls risk, unsafe smoking practices, hoarding magazines.

National Early Warning Score (NEWS2) Assessment

  • Parameters: Respiratory Rate (RR), Oxygen Saturation (SpO₂), Oxygen Therapy, Heart Rate (HR), Blood Pressure (BP), Temperature (Temp), Consciousness (RCP, 2017).
  • Likely Findings:
    • Tachypnea (>24/min)
    • Low SpO₂ (<88–92% target for COPD patients)
    • Increased HR (tachycardia)
    • Possibly febrile if infection is present.
  • Risk: Likely score of ≥5, triggering urgent clinical review.

Incidence and Epidemiology

  • COPD Prevalence: Approximately 1.2 million diagnosed in the UK (~2% of the population), more common in those over 65 years old (British Lung Foundation, 2022).
  • Leg Ulcers: Chronic leg ulcer prevalence is estimated at 1–2% in older adults (Guest et al., 2020).

Aetiology of COPD and Leg Ulcers

  • COPD: Long-term smoking leads to chronic inflammation, resulting in alveolar destruction (emphysema) and airway narrowing (GOLD, 2023).
  • Leg Ulcers: Likely due to underlying venous insufficiency, exacerbated by immobility and poor self-care practices.

Clinical Manifestations and Symptoms

  • Chronic cough, sputum production, breathlessness, wheeze, and recurrent chest infections.
  • Orthopnea (inability to sleep flat).
  • Fatigue, reduced mobility, falls, and social withdrawal.
  • Malodorous, exudative leg ulcers.
  • Weight loss and anorexia (potential for *cachexia* in advanced COPD).

Pathophysiology of COPD and Venous Ulcers

  • COPD:
    • Chronic inflammation causes airway narrowing, mucus hypersecretion, and loss of elastic recoil in the lungs.
    • Gas exchange is impaired, leading to hypoxia and hypercapnia (Barnes et al., 2015).
    • Exacerbation involves increased airway inflammation, infection, sputum production, and worsening breathlessness.
  • Leg Ulcers (Venous):
    • Venous hypertension causes capillary leakage, resulting in oedema and poor tissue healing (O’Meara et al., 2014).

Pharmacological Management

  • Tiotropium (LAMA): A long-acting muscarinic antagonist bronchodilator that relaxes airway smooth muscle (NICE, 2018).
  • Seretide (Fluticasone + Salmeterol): Combination inhaled corticosteroid (ICS) and long-acting beta-agonist (LABA); reduces inflammation and improves symptoms.
  • Antibiotics/Steroids: Likely required during acute exacerbations of COPD (AECOPD).
  • Influenza Vaccine: Essential for preventing viral triggers of exacerbation.

A-to-E Assessment Framework

  • Airway: Ensure patency; assess sputum characteristics and cough effectiveness.
  • Breathing: Monitor RR, SpO₂ (target 88–92% for COPD), accessory muscle use; auscultate for wheeze or crackles.
  • Circulation: Check HR, BP, Capillary Refill Time (CRT), peripheral oedema, and hydration status.
  • Disability: Assess consciousness using AVPU scale; monitor for confusion (risk of CO₂ retention).
  • Exposure: Inspect skin integrity, assess pressure damage risk, examine leg ulcers, check for burns, and evaluate nutritional status.

SBAR Handover Protocol

  • Situation: Brenda Brown, 76 years old, presenting with worsening breathlessness and a productive cough, indicative of a COPD exacerbation.
  • Background: Known history of COPD/emphysema, recurrent infections, chronic leg ulcers, poor mobility, and social isolation.
  • Assessment: Increased shortness of breath (SOB), purulent sputum, likely infective exacerbation. NEWS score is ≥5. Additional concerns include an unsafe home environment, malnutrition, sacral pressure damage, and high falls risk.
  • Recommendation: Request urgent medical review, obtain a sputum sample, consider initiating antibiotics and steroids, titrate oxygen to maintain SpO₂ 88–92%, implement pain and pressure area care, and initiate a social services referral.

Primary and Secondary Diagnoses

  • Primary: Acute Exacerbation of COPD (AECOPD) (GOLD, 2023).
  • Secondary: Chronic leg ulcers, probable malnutrition, pressure damage, risk of self-neglect, and unsafe home environment.

Comprehensive Plan of Care

  • Respiratory Support: Controlled oxygen therapy (88–92% target), administer nebulisers if prescribed, and continuously monitor vital signs.
  • Infection Management: Collect sputum sample for culture, administer prescribed antibiotics and steroids.
  • Skin and Wounds: Regular leg ulcer dressing changes, comprehensive pressure area assessment, and application of barrier creams.
  • Falls Prevention: Occupational Therapy (OT) referral, home safety assessment, and mobility aids review.
  • Nutrition: Dietitian referral, re-evaluation of Meals on Wheels service, and provision of nutritional supplement drinks.
  • Smoking Cessation: Provide intensive support and resources; this is a very high priority intervention.
  • Psychosocial Support: Referral to social services, implementation of a befriending service, and encouragement of family contact.
  • Education: Patient education on correct inhaler technique, symptom monitoring, and clear instructions on when to seek urgent medical help.

Discharge Planning and MDT Input

  • Ensure multidisciplinary team (MDT) input, including the respiratory team, District Nurses (DN), General Practitioner (GP), dietitian, and social services.
  • Establish a robust care package: carers for meals, hygiene assistance, and medication prompts.
  • Enrollment in a structured smoking cessation program.
  • Completion of falls prevention measures and an OT home assessment.
  • Provide a clear COPD action plan (including a rescue pack of antibiotics/steroids if appropriate).
  • Arrange follow-up appointments: respiratory clinic, DN for wound dressings, and GP for medication review.

References

  • Barnes, P.J., Burney, P.G., Silverman, E.K. and Celli, B.R., 2015. Chronic obstructive pulmonary disease. Nature Reviews Disease Primers, 1(1), pp.1–21.
  • British Lung Foundation, 2022. COPD statistics. [online] Available at: https://www.blf.org.uk
  • GOLD (Global Initiative for Chronic Obstructive Lung Disease), 2023. Global Strategy for the Diagnosis, Management, and Prevention of COPD. [online] Available at: https://goldcopd.org
  • Guest, J.F., Fuller, G.W. and Vowden, P., 2020. Venous leg ulcer management in clinical practice in the UK: costs and outcomes. International Wound Journal, 17(3), pp.790–802.
  • National Institute for Health and Care Excellence (NICE), 2018. Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115).
  • O’Meara, S., Cullum, N., Nelson, E.A. and Dumville, J.C., 2014. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews, (11).
  • Royal College of Physicians (RCP), 2017. National Early Warning Score (NEWS2): Standardising the assessment of acute illness severity in the NHS.